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No Surprises Act IDR in California

California: AB 72, the DMHC dispute process, and which claims go federal

Federal IDR vs. California's AB 72 / DMHC independent dispute resolution process for out-of-network providers. Which claims route where, and how we file both.

California is a bifurcated state

California had surprise-billing protections years before the No Surprises Act. AB 72 (2016) covers non-emergency services delivered by out-of-network providers at in-network facilities, and Knox-Keene governs emergency services for plans regulated by the Department of Managed Health Care. Those state rules apply to state-regulated coverage: fully insured employer plans, HMOs, and individual and marketplace plans.

The dividing line: self-funded ERISA employer plans — the majority of commercial coverage in California — are not regulated by the state. Those out-of-network claims go through federal IDR. Misrouting a self-funded claim into the DMHC process (or a fully insured claim into federal IDR) is one of the most common reasons a dispute dies on eligibility.

How the state track differs

  • California's AB 72 framework is built around a payment standard — the greater of the plan's average contracted rate or a Medicare-based benchmark — rather than the baseball-style arbitration used federally.
  • Providers who disagree with the payment can use the DMHC independent dispute resolution process, which reviews whether the amount paid was appropriate.
  • Federal IDR, by contrast, is winner-take-all: the arbitrator picks one offer, and the QPA is only one of several factors.

What we do for California groups

  • Screen every remit for plan type before anything is filed — DMHC/CDI track vs. federal portal
  • Run open negotiation on the correct clock and initiate within the four-business-day federal window
  • Batch federal disputes by payer and service code to hold per-claim costs down
  • Price offers against determination data for the California market, not national averages

State programs and payment standards change. We confirm plan type and the applicable process on every claim before filing.

Which process applies to your claims?

Send 90 days of out-of-network remits. We'll tell you claim by claim: federal IDR, state process, or not disputable — plus what comparable disputes have paid.

Free claims review

Related

How federal IDR works
IDR eligibility checklist
Deadline calculator
Other states

Find out what your out-of-network claims are actually worth.

Send us a sample of recent OON remits. We'll tell you which claims are IDR-eligible, what similar disputes have paid, and what we'd file. No fee unless we win you more.

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